Healthcare Provider Details

I. General information

NPI: 1245367358
Provider Name (Legal Business Name): LISA ROBYN O'CONNOR P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 PEAR AVE # 101
MOUNTAIN VIEW CA
94043-1444
US

IV. Provider business mailing address

PO BOX 8125
FOUNTAIN VALLEY CA
92728-8125
US

V. Phone/Fax

Practice location:
  • Phone: 650-965-8434
  • Fax: 650-965-8545
Mailing address:
  • Phone: 650-965-8434
  • Fax: 650-965-8545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberPT33223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: